Fillable DISABILITY REPORT - APPEAL - Form SSA-3441-BK

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DISABILITY REPORT - APPEAL - Form SSA-3441-BK

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DISABILITY REPORT - APPEAL - Form SSA-3441-BK
READ ALL OF THIS INFORMATION BEFORE YOU BEGIN
COMPLETING THIS FORM
We will use the information that you give us on this form to update your disability report
information for your appeal. We will use the form to update your disability information since
you last completed a disability report. Please complete as much of the form as you can. If
you need help, your interviewer will help you finish it. If you have an appointment for an
interview by telephone, have the form ready to discuss with us when we call you. If you have
an appointment for an interview in our office, bring the completed form with you or mail it
ahead of time, if you were told to do so. If you have access to the Internet, you may access
the Disability Report Form - Appeal instructions at http://www.ssa.gov/online/ssa-3441.html
.
If you are filling out the form for someone else, please provide information about him or her.
When a question refers to "you," "your," or the "Disabled Person," it refers to the person who
is applying for or has been entitled to disability benefits.
HOW TO COMPLETE THIS FORM
•
Print or write clearly.
•
DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer is
"none" or "does not apply," please write: "don't know," or "none," or "does not apply."
•
IN SECTION 3, PUT INFORMATION ON ONLY ONE
DOCTOR/HMO/THERAPIST/OTHER/HOSPITAL/CLINIC IN EACH SPACE.
•
Each address should include a ZIP code. Each telephone number should include an area code.
•
DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THIS FORM.
However, you can get help from other people, like a friend or family member.
•
Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
•
If you need more space to answer any questions or want to tell us more about an answer,
please use Section 10 - REMARKS on Page 7, and show the number of the question being
answered.
ABOUT YOUR MEDICAL RECORDS
If you have any medical records or copies of prescriptions at home, send them to our office
with your completed form or, if you are having an interview in our office, bring them and any
medicine containers with you. If you need the records back, tell us and we will photocopy
them and return them to you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL
RECORDS THAT YOU DO NOT ALREADY HAVE. With your permission, we will do that for
you. The information we ask for on this form tells us to whom we should send a request for
medical and other records. If you cannot remember the names and addresses of your
medical sources, you may be able to get that information from the telephone book, medical
bills, prescriptions, or prescription containers.
Disability Report - Appeal SSA-3441-BK
The Privacy Act
Sections 205(a), 223(d), and 1631(e)(1) of the Social Security Act authorize us to collect
the information on this form. We will use the information you provide on this form to make
a decision on your claim or case. Your response to this request is voluntary. However,
failure to provide all or part of the information could prevent us from making an accurate
and timely decision on your claim or case.
We rarely use the information you supply for any purpose other than for determining your
living arrangements. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another
agency in accordance with approved routine uses, which include but are not limited to the
following: (1) to enable a third party or an agency to assist Social Security in establishing
rights to Special Veterans Benefits; (2) to comply with Federal laws requiring the release
of information from Social Security records (e.g., to the Department of Veterans Affairs);
(3) to make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and (4) to facilitate statistical research,
audit, or investigative activities necessary to assure the integrity of Social Security
programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local
government agencies. Information from these matching programs can be used to establish
or verify a person's eligibility for federally funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs
and systems, is available online at www.socialsecurity.gov or at any local Social Security
office.
The Paperwork Reduction Act
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget control number.
We estimate that it will take about 45 minutes to read the instructions, gather the facts,
and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office
through SSA's website at www.socialsecurity.gov. Offices are also listed under
U. S. Government agencies in your telephone directory or you may call Social
Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our
time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send
only comments relating to our time estimate to this address, not the completed
form.
AFTER COMPLETING THIS FORM, REMOVE THIS SHEET AND KEEP IT
FOR YOUR RECORDS.
Form SSA-3441-BK (08-2010) ef (07-2012)
Use 08-2010 Edition Until Supply Exhausted
SOCIAL SECURITY ADMINISTRATION
DISABILITY REPORT - APPEAL
Form Approved
OMB No. 0960-0144
PAGE 1
For SSA Use Only
Do not write in this box.
Individual
is filing:
Reconsideration
Request for Review by Federal
Reviewing Official
Reconsideration for Disability Cessation
Request for ALJ Hearing
Related SSN
Number Holder
Date of Last
Disability Report
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
A. NAME (First, Middle Initial, Last) B. SOCIAL SECURITY NUMBER
C. DAYTIME TELEPHONE NUMBER (If you do not have a number where we can reach you, give us a
daytime number where we can leave a message.)
Area Code Number
Your Number
Message Number
None
D. Give the name of a friend or relative that we can contact (other than your doctors) who
knows about your illnesses, injuries, or conditions and can help you with your claim or
case.
NAME
RELATIONSHIP
ADDRESS
(Number, Street, Apt. No.(If any), P.O. Box, or Rural Route)
City State
ZIP
DAYTIME
PHONE
Area Code Number
SECTION 2 - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS
A. Has there been any change (for better or worse) in your illnesses, injuries, or conditions
since you last completed a disability report?
Yes No
If "Yes," please describe in detail:
Approximate date the
changes occurred:
Month
Day Year
B. Do you have any new physical or mental limitations as a result of your illnesses, injuries,
or conditions since you last completed a disability report?
Yes No
If "Yes," please describe in detail:
Approximate date the
changes occurred:
Month Day Year
PAGE 2
C. Do you have any new illnesses, injuries, or conditions since you last completed a
disability report?
Yes No
If "Yes," please describe in detail:
Approximate date the
changes occurred:
Month
Day Year
If you need more space, use Section 10 - REMARKS.
SECTION 3 - INFORMATION ABOUT YOUR MEDICAL RECORDS
A. Since you last completed a disability report, have you seen or will you see a
doctor/hospital/clinic or anyone else for the illnesses, injuries, or conditions that limit
your ability to work?
Yes No
B. Since you last completed a disability report, have you seen or will you see a
doctor/hospital/clinic or anyone else for emotional or mental problems that limit your
ability to work?
Yes No
C. List other names you have used on your medical records.
If you answered "NO" to both A and B, go to Section 4 - MEDICATIONS.
Tell us who may have medical records or other information about your illnesses, injuries, or
conditions since you last completed a disability report.
D. List each DOCTOR/HMO/THERAPIST/OTHER. Include your next appointment.
1. NAME
STREET ADDRESS
CITY
STATE ZIP
PHONE
Area Code
Phone Number
PATIENT ID # (If known)
DATES
FIRST VISIT
LAST VISIT
NEXT APPOINTMENT
REASONS FOR VISITS
WHAT TREATMENT DID YOU RECEIVE?
Form SSA-3441-BK (08-2010) ef (07-2012)
PAGE 3
2. NAME
STREET ADDRESS
CITY STATE ZIP
PHONE
Area Code Phone Number
PATIENT ID # (If known)
DATES
FIRST VISIT
LAST VISIT
NEXT APPOINTMENT
REASONS FOR VISITS
WHAT TREATMENT DID YOU RECEIVE?
If you need more space, use Section 10 - REMARKS.
E . List each HOSPITAL/CLINIC. Include your next appointment.
HOSPITAL/CLINIC
NAME
STREET ADDRESS
CITY
STATE ZIP
PHONE
Area Code
Phone Number
TYPE OF VISIT
INPATIENT
STAYS
(Stayed at least overnight)
OUTPATIENT
VISITS
(Sent home same day)
EMERGENCY
ROOM VISITS
DATES
DATE IN DATE OUT
DATE FIRST VISIT DATE LAST VISIT
DATES OF VISITS
Next appointment Your hospital/clinic number
Reasons for visits
What treatment did you receive?
What doctors do you see at this hospital/clinic on a regular basis?
If you need more space, use Section 10 - REMARKS.
Form SSA-3441-BK (08-2010) ef (07-2012)
PAGE 4
F. Since you last completed a disability report, does anyone else have medical records
or information about your illnesses, injuries, or conditions (for example, Workers'
Compensation, insurance companies, prisons, attorneys, or welfare agency), or are you
scheduled to see anyone else?
Yes No
If "YES," complete information below:
NAME
STREET ADDRESS
CITY
STATE ZIP
PHONE
Area Code
Phone Number
DATES
FIRST VISIT
LAST VISIT
NEXT APPOINTMENT
CLAIM NUMBER (if any)
REASONS FOR VISITS
If you need more space, use Section 10 - REMARKS.
SECTION 4 - MEDICATIONS
Are you currently taking any medications for your illnesses, injuries or conditions?
Yes No
If "YES," please tell us the following: ( Look at your medicine containers, if necessary.)
NAME OF MEDICINE
IF PRESCRIBED, GIVE
NAME OF DOCTOR
REASON FOR MEDICINE
SIDE EFFECTS
YOU HAVE
If you need more space, use Section 10 - REMARKS.
Form SSA-3441-BK (08-2010) ef (07-2012)
PAGE 5
SECTION 5 - TESTS
Since you last completed a disability report, have you had any medical tests for illnesses,
injuries, or conditions or do you have any such tests scheduled?
Yes No
If "YES," please tell us the following: (Give approximate dates, if necessary.)
KIND OF TEST
EKG (HEART TEST)
TREADMILL (EXERCISE TEST)
CARDIAC CATHETERIZATION
BIOPSY -- Name of body part
HEARING TEST
SPEECH/LANGUAGE TEST
VISION TEST
IQ TESTING
EEG (BRAIN WAVE TEST)
HIV TEST
BLOOD TEST (NOT HIV)
BREATHING TEST
X-RAY -- Name of body part
MRI/CT SCAN -- Name of body
part
WHEN WAS/WILL
TEST BE DONE?
(Month, day, year)
WHERE DONE?
(Name of Facility)
WHO SENT YOU FOR
THIS TEST?
If you need more space, use Section 10 - REMARKS.
SECTION 6 - UPDATED WORK INFORMATION
Have you worked since you last completed a disability report?
Yes No
If "YES," you will be asked to give details on a separate form.
SECTION 7 - INFORMATION ABOUT YOUR ACTIVITIES
A. How do your illnesses, injuries, or conditions affect your ability to care for your personal
needs?
Form SSA-3441-BK (08-2010) ef (07-2012)
PAGE 6
B. What changes have occurred in your daily activities since you last completed a
disability report?
If none, show "NONE."
If you need more space, use Section 10 - REMARKS.
SECTION 8 - EDUCATION/TRAINING INFORMATION
Have you completed any type of special job training, trade or vocational school since you
last completed a disability report?
Yes No
If "YES," describe what type:
Approximate date completed:
SECTION 9 - VOCATIONAL REHABILITATION, EMPLOYMENT, OTHER SUPPORT
SERVICES INFORMATION, OR INDIVIDUALIZED EDUCATION PROGRAM
Since you last completed a disability report, have you participated, or are you participating in:
•
an individual work plan with an employment network under the Ticket to Work Program;
•
an individualized plan for employment with a vocational rehabilitation agency or any other organization;
•
a Plan to Achieve Self-Support;
•
an individualized education program through an educational institution (if a student age 18-21); or
•
any program providing vocational rehabilitation, employment services, or other support services to help
you go to work?
Yes No
If "YES," complete the following information:
NAME OF ORGANIZATION OR SCHOOL
NAME OF COUNSELOR OR INSTRUCTOR
ADDRESS
(Number, Street, Apt. No.(if any), P.O. Box, or Rural Route)
City State ZIP
DAYTIME PHONE NUMBER
Area Code
Number
DATES SEEN TO
TYPE OF SERVICES,
TESTS, OR EVALUATIONS
PERFORMED
(IQ, vision, physicals, hearing, workshops, classes, etc.)
Form SSA-3441-BK (08-2010) ef (07-2012)
PAGE 7
SECTION 10 - REMARKS
Use this section for any additional information you did not show in earlier parts of this
form. When you are finished with this section (or if you don't have anything to add), be
sure to go to the next page and complete the blocks there.
Form SSA-3441-BK (08-2010) ef (07-2012)
PAGE 8
SECTION 10 - REMARKS
Name of person completing this form if other than the disabled
person (Please print)
Date Form Completed (Month, day, year)
E-Mail Address of person completing this form (optional)
If the person completing this form is other than the disabled person or the person identified in Section 1. Item D.,
please complete the following information.
Relationship to Disabled Person Daytime Telephone Number
Address (Number and street)
City State ZIP
Form SSA-3441-BK (08-2010) ef (07-2012)
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DISABILITY REPORT - APPEAL - Form SSA-3441-BK

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Completed 14 May 2021

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